DR. LYNN FRIEDMAN'S BLOG, "ALL THINGS PSYCHOANALYTIC"

Private Practice Life - Dr. Lynn Friedman - Johns Hopkins - Developing a Private Practice - Course blog

 Dear All,

Happy New Year!!!!

I teach, the Johns Hopkins course, "Developing a Successful Private Practice" in the Clinical-Counseling program. Also, I teach, "Introduction to Psychodynamic Theory and Therapy". In the fall, when I taught my graduate students asked for more. They wanted more information on: how to develop their clinical passions, how to deepen their self-awareness, how to more comprehensively develop their skills,  and how to prepare for life as a private practitioner. That is, specifically, they wanted to know: what can I do to become a skilled clinician and an effective private practitioner? Some were worried about obtaining referrals.  All were interested in developing effective methods of providing good, helpful care to their patients. Having been in private practice for many years, my experience has been that dedicating ones professional life to life-long learning and teaching leads to becoming an increasingly skilled clinician.  And, that, in turn leads to a successful private practice.  Of course, that's easier said then done.  So, I've written a blog about it.

I love my professional life and everything that goes with it!  I love my clinical practice. I love doing evaluation, psychotherapy and psychoanalysis. I love supervising and consulting to psychotherapists. I love teaching. I love community education and outreach and I love reading and writing about these very compelling endeavors.  So, I decided to write about it, not only for my graduate students but with all of the clinicians and clinicians-in-the-making who share this interest.

As for your questions:  if you are in my class, please send them to me. If I can't answer them here, then, I'll try to answer them in class. If you are not in the class, feel free to send me your questions, too. I'll do my best to answer them. But, I can't guarantee it as I'm in full-time private practice and my after work hours are largely devoted to family and friends.

Confidentiality

I take confidentiality very seriously. For reasons of confidentiality and copyright, I will not be publishing your questions.  I'll share them in the aggregate.  I will not be writing about real patients.  I will create fictitious patients -- people with whom we can all identify.  Undoubtedly, we will all recognize ourselves in some of these vignettes because they will be fairly universal.  Part of the private practice life entails zealously guarding the confidences with which we are entrusted, the more respectful we are of our patients and clients, the more respectful they become of themselves.

A Tripartite Model for the Private Practice Life

Over the years, I've developed a tripartite model for becoming a skilled clinician.  In my opinion, having a gratifying professional life in the private practice of psychotherapy entails three cornerstones:  (1) finding a way of continually deepening our understanding of and empathy for our patients, our clients, and ourselves. This entails obtaining one's own treatment, supervision and consultation with an eye towards dealing in an increasingly skillful way with patient situations. This growing capacity allows us to use ourselves in the service of the people who we see. Also, it entails creating a work-life balance. (2) designing and implementing a life long, professional development program. This includes developing a primary area(s) of expertise. (3) finding a gratifying and fulfilling way to educate ourselves, our colleagues, and the public and policy makers about one's primary area of specialization.

Over the years as I've practiced, I've treated, supervised, consulted to and taught clinicians at various stages of their professional development ranging from advanced undergraduates at Carnegie Mellon University, University of Pittsburgh medical students and residents at the University of Pittsburgh School of Medicine, clinical counseling graduate students at Johns Hopkins University, postgraduate psychoanalytic psychotherapy students at the Baltimore Washington Psychoanalytic Institute, candidates at the Washington Center for Psychoanalysis and others.  In the context of doing this work, I have found that these three cornerstones provide the bulwark for developing strong and effective therapeutic relationships with patients. This in turn, has led to developing a fulfilling, helpful private practice.

In this blog, I'll be posting nearly everyday until class begins on April 2nd.  I'll talk about a range of clinical and practice issues.  But mostly, my focus will be on taking good care of the patients who we see.  

Finally, a note about copyright. Feel free to forward these blog posts to your friends and your friend's friends and elsewhere. However, in doing so, please remember that all material is copyrighted and please be respectful of that copyright. Thank you.

A note to my graduate students in the, "Developing a Private Practice", course.

Do you have to read this blog?  No. Not yet. This course will not begin until April 2, 2010.  However, those who read the blog - and, think about what they are reading will find that they are more fully prepared for the course than they might otherwise be.  Also, if you read the blog and you comment on it and ask questions, I will be more fully prepared to address your needs when we meet in the spring.

How do you find out about new postings?  You can sign up for the blog. You can follow me on twitter. Eventually you will be able to sign up on my fan page on facebook; but, I am not there yet.

I look forward to meeting you all in April.  As for now, best wishes for a restful break and a Happy New Year.

Sincerely,

Lynn Friedman, Ph.D.

P.S. The waiting list to take this class has grown. Therefore, Johns Hopkins has added a second session to be taught the last weekend in April. Already practicing professionals and graduate students from elsewhere may enroll as special students. The course will run from 9:00 am - 4:00 pm on Friday and Saturday. Information about registration may be obtained through the university.

P.P.S. A list of all blog posts can be found at: Dr. Lynn Friedman's, developing a private psychotherapy practice

(c) January 1, 2010  - Lynn Friedman, Ph.D. All rights reserved.

Confidentiality Policy:  Please note for reasons of confidentiality and copyright all letters to the blogger will be summarized and edited. Also,  I will not write about real patients. Instead, I will create fictionalized vignettes.  When you pose a clinical question, please ask it in a general way.  DO NOT write about real patients.   Thank you.
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Lynn Friedman, Ph.D.
Psychologist, psychoanalyst, work-life consultant
Faculty Associate, Johns Hopkins University
5480 Wisconsin Avenue
Chevy Chase, MD 20815
301.656.9650
www.drlynnfriedman.com
www.corporationsonthecouch.com
www.drlynnfriedman.typepad.com
www.twitter.com/drlynnfriedman
For those seeking, evaluation for psychotherapy, psychoanalysis, supervision or consultation, I welcome your call.
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Posted via email from drlynnfriedman's posterous

Treatments for anxiety disorder

Anxiety disorder treatment is highly effective. You have read about thesymptoms of anxiety and depression. And, you have read about when everyday anxiety becomes generalized anxiety disorder. But, what sorts of anxiety disorder treatments are effective?

< http://www.washington-dc-psychologist.com/anxiety-disorder-treatment.html>

Everyday anxiety OR anxiety disorder

 
Everyday Anxiety
Anxiety disorder is an extremely prevalent psychological difficulty. However, most anxiety is not "anxiety disorder". Rather, everyone experiences anxiety. In small amounts it can be useful. It can serve as a warning signal that something isn't quite right. Take a classic example, undoubtedly familiar to anyone who has been a student. 
< http://www.washington-dc-psychologist.com/anxiety-disorder.html >

How do you assess whether you should seek assessment for anxiety or depression

Anxiety and depression are nearly universal. Who hasn't experienced, "stress" or the "blues". And, these difficulties frequently occur together. The term, "mixed anxiety-depressive disorder", is applied to those who suffer from both. Feeling worried or down at times is part of the human condition. But, how does one know when everyday anxiety and depression turn into more serious difficulties? And, how does one know when these difficulties warrant psychological evaluation?

< http://www.washington-dc-psychologist.com/symptoms-of-anxiety-and-depression.html>

Famous people in psychoanalysis - documentary - interesting

The first lady of France found psychoanalysis useful and she is not alone. The film depicts other celebrities who found this treatment helpful. 

<http://www.zimbio.com/Carla+Bruni-Sarkozy/articles/hMZfgu5ZalG/Bruni+Sarkozy+tells+8+years+psychoanalysis>

Developing a Successful Private Practice - When the Therapist is Late: Dr. Lynn Friedman - Johns Hopkins

I am reposting Sarah Gilden's comment:

Dr. Friedman, This post made me wonder what you do if you, the therapist, is the one who is going to be late. How do you make sure that your client does not feel as if your lateness is a reflection of your feelings for them? Have you ever has an experience (or heard of someone else's experience) where there was a negative impact on the therapeutic relationship as a result of the therapist being late and/or cancelling/rescheduling sessions? This also brings up the question of best how to handle vacations or time away. Obviously there is someone covering for you in some way, but what does that really look like for both you and the client, and how do you decide who is a good person to do this for you? Thanks so much, Sarah

When the Therapist is Late

Though we try our best, it happens. Your car breaks down, a family member has a crisis, an earlier patient has an emergency, you are late. Not only that to add insult to injury there's an inherent inequity in the situation: When the patient is late, you still end the session on time. In contrast, when you are late, you make an accommodation.  Patients are bound to have feelings about this.  The key here, in my opinion, is to listen and clarify their feelings.  And, whatever you do don't make life more complicated by apologizing at the beginning of the session. Instead, say that you are late - if you are able to extend the session ask the patient if that is acceptable, if not, arrange a suitable alternative. 

Why do I suggest that you not apologize at the beginning of the session?

It flies in the face of every consumer oriented bone in your body.  If you apologize, the patient is virtually obligated to say, "that's O.K.".  But, odds are, it's not!  And, this is what you want to hear about.  You want to hear exactly how the patient feels. They are not there to assuage your guilt, your guilt is your problem. That's why you are paid the big bucks.  So, instead, you announce that you are late. Then, ideally, you listen quietly. 

If the patient is quiet you might say, I wonder if you have any thoughts about your silence? Or, I wonder if your silence has something to do with your feelings about my lateness.  Or perhaps you may have some ideas or fantasies about why I was late (you do not tell them why, as a general rule, with some real, significant exceptions.) And, you encourage the patient to say whatever comes to mind. 

The patient may not address your lateness directly. Instead, if you listen carefully, you'll find that you are hearing about a late boss who acts cavalier about when he comes and goes or the tardy parent who is insensitive to the patient's needs for timeliness or some other bad-acting, key authority figure. This is because for many patients, their feelings about your lateness are quite unconscious.  If, indeed, the patient is talking about your lateness in the displacement, you can gently wonder if perhaps they experienced you -- and, your lateness as akin to the cavalier boss - after all you might say, "if you are late I don't extend the hour - whereas I am late I do - perhaps that feels that I am being highhanded as with your boss, etc".

If the therapeutic alliance is strong or the patient has an unusual amount of ego strength, she may be able to tell you directly what her fantasies are about your lateness.  The patient may worry that you had an emergency or were somehow not O.K. or she may fear (as Sarah suggested) that it reflects your feelings about her.  She may worry about whether you like her, whether you want to see her, whether you want to hear what she has to say or a myriad of other things. It's very important to listen, in a non-judgmental, not defensive way and for you to tolerate her hurt or vulnerable feelings.  As for your need to apologize, hold it for the end of the session. Often you will find that if you have understood and accepted her feelings, your unspoken apology has been felt.

I am looking forward to meeting you all!!!

Best, LVF

Developing a Successful Private Practice - Psychiatric Diagnosis: Dr. Lynn Friedman - Johns Hopkins

My feelings about diagnosis, a la the DSM, are twofold. First, I think that this sort of diagnosis CAN be useful in two ways. If a person has a disorder in which psychopharmacology can be a useful adjuvant to psychotherapy, then it can be very helpful to provide a diagnosis. For example, schizophrenia and bipolar illness often yield to psychopharmacological intervention. I am not in any way denigrating the very important role that psychotherapy can play in addressing these difficulties (as I believe its' role has been empirically documented). Rather, I feel that medicine has an equally important role to play with these sorts of problems. In fact, failure to diagnose the presence of these difficulties is a very serious problem, indeed. Providing this diagnosis to the consulting psychiatrist can play a vital role in ensuring that these patients are treated in a helpful fashion.

On an unrelated vein, insurance companies require diagnoses, a la the DSM, in order to reimburse the patient. Although this feels, to me, a little bit like the tail wagging the dog, my own feeling is that it is important to provide these sorts of diagnoses, for insurance purposes, if (and, only if) the patient requests it.

Beyond these two purposes, I rarely (with some exceptions) provide DSM diagnoses. Let me start with the exceptions and then return to my general practice.

As I've already said, if a patient is suffering from a major mental illness - psychoses or major depression (bipolar or to use the old nomenclature, serious unipolar illness), I will provide a DSM diagnosis. Substance abuse and borderline personality disorders are other arenas in which I might provide such diagnoses. My main goals here are - to inform the psychiatrist and other ancillary clinicians (e.g. family therapists, couple's therapists, etc.) of my assessment of the difficulties and most importantly to inform the patient. That having been said, the matter of diagnosis is delicate and requires tact. It should certainly not be brought up at the end of the session. Rather, the patient needs time to express and explore their feelings about it.

It has been my experience, in these situations, that if diagnosis is diplomatically addressed, that many, though not all, patients experience a significant relief in being given a diagnosis.

That having been said, I do not diagnose most of my patients with DSM diagnoses UNLESS it is required for insurance purposes. This is because most of the people who I see are mental health professionals, (psychologists, counselors, social workers), physicians, lawyers (as I practice here in Washington), an array of other professionals and their teenage and adult children. Most of my patients are suffering from what we used to call psychoneuroses in the old days: anxiety, depression, dysthymia, relationship difficulties, troubled family relationships, career difficulties, problems getting along with others, self-esteem difficulties, problems with narcissism, etc. Although many fit the categories in the DSM (as these categories are so overbroad nearly everyone can fit somewhere), I just don't find it very helpful to label them. In fact, labels can have an iatrogenic effect. And they can be circular. For example: "I have an anxiety disorder so I act anxious." Now, what does that really tell anyone and how does it help the patient? I don't find that this sort of labeling leads to a deepening of ones self-awareness.

However, I do feel that, following a careful psychological evaluation, I am obligated to provide the patient a very clear and explicit formulation as to how I understand their difficulties and how I feel that they can be effectively addressed. In my opinion, this should be synced up with why they have their presenting problem. This sort of formulation is, in my opinion, different than diagnosis in that it clearly addresses the patient's unique struggles and strengths. It informing as opposed to categorizing and stigmatizing. Just my thoughts.

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Lynn Friedman, Ph.D.
Psychologist, psychoanalyst, work-life consultant
Faculty Associate, Johns Hopkins University
5480 Wisconsin Avenue
Chevy Chase, MD 20815
301.656.9050
http://www.drlynnfriedman.com
http://www.corporationsonthecouch.com
http://www.drlynnfriedman.typepad.com
http://www.twitter.com/dcpsychologist
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Setting Fees - An Overview - Dr. Lynn Friedman, Johns Hopkins Private Practice Course Blog

Setting the fee by Dr. Lynn Friedman, Johns Hopkins

Clinicians new to private practice often have neither experience, nor comfort in, setting fees.  To begin with those early in their careers may be uncertain about three things:  (1) whether patients will actually call, (2) whether patients will pay and, most importantly, (3) whether what they have to offer is truly of value.  These three concerns make the fee setting and/or fee negotiating very anxiety producing, indeed.  Add to that the patient's anxiety and we have a recipe rife with the potential for enactments.  Let's talk today about the clinician's contribution to this mix.

Anxiety about attracting patients

On first blush, an obvious solution to this predicament seems to be having more patients calling then you can possibly treat. That is, of course, more easily said then done. It is, however, an essential ingredient to having a successful, effective, private psychotherapy practice.  And, that is one of the reasons why this blog focuses considerable attention on how to generate referral.  Having more patients calling then one could possibly treat puts the clinician in the position of being able to focus on and think about (1)whether he is the best clinician for a particular patient (2) what fee is most appropriate for the patient; (3) what fee he feels comfortable accepting. Of course, being a sought after clinician does not alter the anxiety inherent in assuming the weighty responsibility for taking care of patients. And, more will be said about that in future posts.

(1) Will patients call?

The new private practitioner, even one with many years of clinical experience, is understandably apprehensive. Will patients call?  If it hasn't dawned on him in the past as he signs his first lease or buys his first office, he becomes acutely aware that he is not only a clinician but the owner a small business.  He has to pay rent, keep books, and, most importantly he must ensure that his care is reliable and of high quality.  This places him in quite a precarious position so far as his patients are concerned: he needs them.  And, I should note parenthetically that patients, already in a high state of alert, can sense that. There is much more to be said about that fact, but I shall reserve that for a subsequent post.  For now, let us say that the practitioner is in that awkward, untenable position of needing patients.  At this early juncture, it is perhaps naive and insensitive to say that this position of, "needing patients" gives the practitioner a whiff of what patients feel when they entrust themselves to our care.  But, it's worthy of note that, in this regard, both patient and clinician are in the same, anxiety producing boat. This anxiety about referrals may make the clinician anxious when he is called upon to set fees.

(2) Will patients pay?

Patients have many feelings about the fee that they pay. With prospective patients it's important to be clear and straightforward about your fee. Ideally, one alerts them to the fee either during the initial phone call or in the first session.  This is important because some, for example, those for whom therapy is a maiden voyage, may imagine that their insurance will cover your services. Unless you work for managed care this is unlikely so it's important to clarify that at the outset.  At the end of the initial phone call, after setting the first appointment and providing the office address one might, say, "my fee is x", and that is payable at the time of the session (or at whatever time the clinician intends to collect the fee).  Is that O.K. with you?  This opens the door for the patient to assert that he plans to use his insurance or that he wishes to be seen on a sliding scale basis. 

Another alternative, of course, is to wait until the first session and state your fee, 15 minutes before the end of the session. This allows you to explore the patient's feelings about it - and, to try to understand those feelings in light of the patient's financial realities as well as their unconscious fantasies.  There is much more to be said about this, including: what sorts of fantasies do patient's have about the clinician's fee, should you have a sliding scale and if so, how should you set fee?  These topics will be fodder for a subsequent post.  For now, it seems important to point out that most new private practitioners are anxious about setting fees because they harbor the apprehension that they will lose patients. While this is true, at times, setting fees early on and clearly is an important aspect of the therapeutic frame. Clarity about them is reassuring to the patient.

(3) Is the clinician worth what he charges?

When the patient hears the clincian's fee, often, he wonders, is it worth it?  Therapy requires a commitment of time and money but these are not the worst of the patient's anxieties.  Rather, at both a conscious and unconscious level, he is aware that therapy can be painful.  And, on top of all of this, he is expected to pay for it!  While it is understandable that the patient would lament or question the cost of psychotherapy, it can be daunting to the new private practitioner who may have questions about his own skills.

An empathic tone coupled with an attempt to clarify both affective and reality based anxieties about the fee can prove most useful. Also, should the reality exigencies make the fee burdensome, the clinician ought to be respectful of those concerns either by reducing the fee or by referring to a low fee setting.  Of course, it can be challenging to differentiate between neurotic anxieties and reality anxieties, especially when both clinician and patient are embarking on this new relationship.  The best antidote to that is ongoing supervision or consultation with a clinician who is skilled both clinically and in the art of private practice. In this way, uncertainties can be expressed, clarified and addressed in the consultative setting. And, then the clinician can return to the clinical setting prepared to set his own anxieties aside and empathize with the patient. 

There is much more to be said about these important topics and they will be addressed in more detail in future posts.

Best to all, Lynn Friedman, Ph.D.

(c) 2010 Lynn Friedman, Ph.D. All rights reserved 

P.S. The waiting list to take this class has grown. Therefore, Johns Hopkins has added a second session to be taught April 30/May1. Already practicing professionals and graduate students from elsewhere are welcome to enroll as special students. The course will run from 9:00 am - 4:00 pm on Friday and Saturday. Information about registration may be obtained through the university. Some clinicians from out-of-town universities and practices have expressed an interest in attending and they are most welcome as it is only a 2 day course.

P.P.S. A list of all blog posts can be found at: http://www.drlynnfriedman.typepad.com

Confidentiality Policy: Please note for reasons of confidentiality and copyright all letters to the blogger will be summarized and edited. Also, I will not write about real patients. Instead, I will create fictionalized vignettes. When you pose a clinical question, please ask it in a general way. DO NOT write about real patients. Thank you.

//////////////////////////////////////////////////////////////////////////////

Lynn Friedman, Ph.D.

Psychologist, psychoanalyst, work-life consultant

Faculty Associate, Johns Hopkins University

5480 Wisconsin Avenue

Chevy Chase, MD 20815

301.656.9650

Follow the private practice blog

http://www.drlynnfriedman.com/about.html

http://www.corporationsonthecouch.com

Dr. Lynn Friedman welcomes referrals for supervision or consultation, feel free to call.

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Developing a Successful Private Practice - Efficacy of Talk Therapy: Dr. Lynn Friedman - Johns Hopkins

Scientific American - The Efficacy of Talk Therapy

Developing a Private Practice - Course blog: The DSM-5 - Some troubling mistakes - Johns Hopkins -Dr. Lynn Friedman

<http://www.psychiatrictimes.com/display/article/10168/1522341?pageNumber=1&verify=0> Read this and consider the implications!  Best to all. LVF

Developing a Private Practice - Course blog: Job at Gtown Counseling Center - Johns Hopkins -Dr. Lynn Friedman Read a summary of Shedler's work.

<http://www.washingtonpost.com/wl/jobs/JS_JobSearchDetail?jobid=28760457&jobSummaryIndex=0&agentID=&xfeed=1&wpmk=MK0000005&GCID=C17812x034> This looks like a good job for a recent grad.